Rationales maternal/newborn quiz bank 23

A nurse is teaching a client about squatting exercises during pregnancy. Which of the following statements should the nurse include?

"These exercises should be done for 15 minutes each day to strengthen the perineal muscles."

A nurse is performing a nonstress test (NST) on a client who is at 41 weeks of gestation. The client asks what the purpose of the test is. Which of the following responses should the nurse provide?

"This test will help determine if your baby is healthy."

A nurse is caring for a client who is pregnant. The client asks, "Is it okay to have a few beers while I'm pregnant?" Which of the following responses should the nurse make?

"Total abstinence from alcohol is recommended."

A nurse is providing education to a client who is at 34 weeks of gestation about a non-stress test (NST). Which of the following pieces of information should the nurse include?

"You might have to drink orange juice during the test."

A nurse is teaching a client who has active genital herpes simplex virus, type 2. Which of the following statements should the nurse include in the teaching?

"You will have a cesarean birth prior to the onset of labor."

A nurse is providing teaching about calcium intake to a client who is breastfeeding. Which of the following is the recommended daily calcium intake for a client who is breastfeeding?

1,000 mg

A nurse is caring for a client who reports intestinal gas pain following a cesarean section. Which of the following actions should the nurse take?

Assist the client to ambulate in the hallway

A nurse is caring for a client who is in labor. The client speaks a different language than the nurse and is grimacing. Which of the following actions should the nurse take while waiting for an interpreter?

Change the client's position

A nurse is developing a plan of care for a newborn who has hyperbilirubinemia and a prescription for phototherapy. Which of the following interventions should the nurse include in the plan?

Change the newborn's position every 2 to 3 hours

A nurse is providing care to a client who is in labor. A fetal heart tracing shows early decelerations. Which of the following actions should the nurse take?

Continue to monitor the fetal heart tracings

A nurse is assessing a postpartum client who reports strong contractions whenever she breastfeeds her newborn. The nurse should respond with which of the following statements?

D. "The same hormone that is released in response to the baby's sucking and causes milk to flow also makes the uterus contract."

A nurse is caring for a client who has eclampsia and just had a tonic-clonic seizure. After turning the client's head to the side, which of the following actions should the nurse take next?

Give oxygen at 10 L/min via face mask

A nurse is reviewing the laboratory report of a newborn who has a blood type of B-negative. The mother's blood type is O-positive. The laboratory results indicate the direct antiglobulin test is positive. Which of the following complications should the nurse anticipate?

Hyperbilirubinemia

A nurse is assessing a client who has placenta previa. Which of the following findings should the nurse expect?

Painless, bright red bleeding

A nurse is caring for a client who is at 38 weeks of gestation and is receiving an oxytocin IV for labor augmentation. The nurse notes variable decelerations on the FHR tracing. Which of the following actions should the nurse take first?

Place the client in a side-lying position

A nurse is assessing a 4-hour-old newborn prior to breastfeeding and notes hands and feet that are cool and slightly blue. Which of the following actions should the nurse take?

Place the naked newborn on the mother's bare chest and cover both with a blanket

A nurse is caring for a client who is in labor and has fetal heart tracings of variable decelerations. Which of the following actions should the nurse take?

Reposition the client from side to side

A nurse is preparing to perform Leopold maneuvers on a client who is in labor. Which of the following actions should the nurse plan to take?

Stand at the client's right side if the nurse is right-handed

A nurse is assessing a newborn who was born at 39 weeks gestation. Which of the following findings should the nurse expect?

Symmetric rib cage

A nurse is assessing a newborn who was circumcised 24 hours ago. Which of the following findings should the nurse report to the provider?

The newborn has urinated once since the circumcision

A nurse is assessing a client at 37 weeks gestation who has a suspected pelvic fracture due to blunt abdominal trauma. Which of the following findings should the nurse expect?

Uterine contractions

A nurse administers betamethasone to a client who is at 33 weeks gestation to stimulate fetal lung maturity. When planning care for the newborn, which of the following conditions should the nurse identify as an adverse effect of this medication?

Decreased blood glucose

A nurse is teaching a client during the client's first prenatal visit. Which of the following instructions should the nurse include?

"A Doppler device can detect your baby's heart rate at 12 weeks."

A nurse is providing postpartum discharge teaching for a client who is breastfeeding. The client states, "I've heard that I can't use any birth control until I stop breastfeeding." Which of the following responses should the nurse make?

"A progestin-only pill or injection is available for use while you are breastfeeding."

A nurse is teaching a client who is postpartum and breastfeeding. Which of the following statements should the nurse include?

"A reduction in sexual interest could indicate postpartum depression."

A nurse is discussing epidural anesthesia with a client who is receiving oxytocin to induce labor. Which of the following statements should the nurse make?

"An epidural given too early can prolong labor."

A nurse is reinforcing teaching about preventing engorgement to a client who is planning to use formula to feed her newborn. Which of the following instructions should the nurse include?

"Apply ice packs to your breasts."

A nurse is teaching about preventing engorgement to a client who is planning to use formula to feed her newborn. Which of the following instructions should the nurse include?

"Apply ice packs to your breasts."

A nurse at a prenatal clinic is teaching a client how to perform a kick count. Which of the following statements should the nurse include in the teaching?

"Before bedtime is a good time to start counting the kicks."

A nurse is assisting a client who is 4 hr postpartum to get out of bed for the first time. The client becomes frightened by a gush of dark red blood from her vagina. Which of the following statements should the nurse make in response?

"Blood pools in the vagina when you are lying in bed."

A nurse is caring for a client who is 32 hours postpartum. The client reports nipple soreness and breast engorgement. Which of the following recommendations should the nurse provide?

"Call me so I can check your baby's latch the next time you breastfeed."

A nurse is teaching a client who is pregnant and has pregestational diabetes about dietary changes. Which of the following statements should the nurse include in the teaching?

"Carbohydrates should make up 55% of your diet."

A nurse is teaching a parent of a newborn how to care for the newborn's umbilical cord stump. Which of the following instructions should the nurse include?

"Clean the cord stump with tap water."

A nurse is providing discharge instructions to the parent of a newborn. Which of the following statements should the nurse include?

"Crib slats should be less than 2.25 inches apart."

A nurse is assessing a client who is at 20 weeks gestation and reports frequent episodes of indigestion and heartburn. Which of the following instructions should the nurse give to the client?

"Decrease your intake of spicy foods."

A nurse is providing discharge teaching to a client following the removal of a hydatidiform mole. Which of the following statements should the nurse include in the teaching?

"Do not become pregnant for at least 1 year"

A nurse is providing discharge teaching to a client following the removal of a hydatidiform mole. Which of the following statements should the nurse include in the teaching?

"Do not become pregnant for at least 1 year."

A nurse is teaching a female client about nutrition during pregnancy. Which of the following instructions should the nurse include in the teaching?

"Do not eat swordfish, shark, or king mackerel while you are pregnant."

A nurse is providing teaching to a client who is 1 hour postpartum about using the perineal squeeze bottle. Which of the following instructions should the nurse include?

"Fill the perineal bottle with warm water prior to use."

A nurse is caring for a client who is in labor and asks her partner to perform effleurage. The client has on a monitor belt for electronic fetal monitoring. Which of the following instructions should the nurse provide to the client's partner?

"Firmly squeeze both hips."

A nurse is caring for a client who has a BMI of 22.6 and expresses concern about weight gain during pregnancy. Which of the following responses should the nurse make?

"Gaining weight will promote a healthy pregnancy."

A nurse is teaching a prenatal class about pain management during labor. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"I can apply a heating pad to my back to relieve back pain."

A nurse is administering a rubella immunization to a client who is 2 days postpartum. Which of the following client statements indicates a need for further instruction?

"I can conceive anytime I want after 10 days."

A nurse is caring for a client who is in labor. The client asks the nurse, "Why are you pressing on my abdomen?" Which of the following responses should the nurse make?

"I can determine the position of your baby."

A nurse is teaching a client about breastfeeding. Which of the following client statements indicates an understanding of the teaching?

"I may notice increased cramping when I am feeding my baby."

A nurse is teaching a parent how to care for his newborn's circumcision site. Which of the following client statements indicates an understanding of the teaching?

"I should apply the diaper loosely until the circumcision site is healed."

A nurse is evaluating a client who has just received instructions about breastfeeding. Which of the following statements should the nurse identify as an indication that the client understands how to prevent mastitis?

"I should avoid waiting too long between feedings."

A nurse is providing teaching about the rubella immunization to a client who is 24 hours postpartum. Which of the following client statements indicates an understanding of the teaching?

"I should be careful to avoid becoming pregnant within the next month."

A nurse is providing breastfeeding education to a client who delivered 12 hours ago. Which of the following client statements indicates an understanding of the teaching?

"I should breastfeed at least 8 to 12 times in a 24-hour period."

A nurse is providing teaching for a postpartum client who is breastfeeding. Which of the following statements indicates an understanding of the teaching?

"I should feed my baby 8-12 times a day, based on feeding cues."

A nurse is teaching a client at 13 weeks gestation about the treatment of incompetent cervix with cervical cerclage. Which of the following statements by the client indicates an understanding of the teaching?

"I should go to the hospital if I think I may be in labor."

A nurse is providing teaching for a client at 7 weeks of gestation who is experiencing nausea and vomiting. Which of the following client statements indicates to the nurse an understanding of the teaching?

"I should have a small snack before bedtime."

A nurse is providing nutritional teaching for a pregnant client who had a prepregnancy body mass index (BMI) of 38. Which of the following statements by the client demonstrate an understanding of the teaching about her recommended weight gain during pregnancy?

"I should plan to gain 5 to 9.1 kg during my pregnancy."

A nurse is teaching a client about a nonstress test. Which of the following statements by the client indicates an understanding of the teaching?

"I should press the button on the handheld marker when my baby moves."

A nurse is providing teaching about home care to the parent of a newborn. Which of the following statements indicates an understanding of the teaching?

"I should remove the bumper pad and stuffed toys from my baby's crib."

A nurse is discussing diaphragm use with a client. Which of the following statements by the client indicates an understanding of the teaching?

"I should replace my diaphragm every 2 years."

A nurse is teaching a postpartum client how to swaddle her newborn. Which of the following statements by the parent demonstrates an understanding of the teaching?

"I should stop swaddling my baby once she is able to roll over by herself."

A nurse is explaining lactation suppression to a client whose newborn will be bottle-fed. Which of the following client statements indicates an understanding of the teaching?

"I should wear a support bra for a few days."

A nurse is teaching about mastitis to a client who is postpartum and breastfeeding her newborn. Which of the following statements by the client indicates an understanding of the teaching?

"I will avoid any of my family members who are ill."

A nurse is providing postpartum discharge teaching about proper storage of breast milk for a client who is breastfeeding. Which of the following client statements indicates an understanding of the teaching?

"I will discard any unused breastmilk that is left in the bottle."

A nurse is teaching a client who is in labor about the use of nitrous oxide analgesia for pain control. Which of the following statements by the client indicates an understanding of the teaching?

"I will feel the effects of the nitrous oxide almost immediately."

A nurse is providing counseling for a couple experiencing infertility issues. Which of the following statements by the nurse is appropriate?

"You might want to join our support group for couples who are experiencing similar problems."

The nurse is teaching a client who is postpartum about the rubella vaccine. Which of the followings statements should the nurse include?

"You must not become pregnant for 28 days after receiving this immunization."

A nurse is teaching a client who is pregnant about toxoplasmosis. Which of the following instructions should the nurse include?

"You should avoid gardening during your pregnancy to decrease your risk of contracting toxoplasmosis."

A nurse is teaching a client who is at 12 weeks gestation and has human immunodeficiency virus (HIV). Which of the following statements should the nurse include in the teaching?

"You should continue to take zidovudine throughout the pregnancy."

A nurse is educating a client who is at 10 weeks gestation and reports frequent nausea and vomiting. Which of the following statements should the nurse include in the teaching?

"You should eat dry foods that are high in carbohydrates when you wake up."

A nurse is caring for a pregnant client who reports nausea and vomiting. Which of the following instructions should the nurse share with the client?

"You should eat some crackers before rising from bed in the morning."

A nurse is providing teaching for a client who is pregnant and has type 1 diabetes mellitus. Which of the following statements should the nurse include in the teaching?

"You should expect to decrease your insulin dosage immediately after you deliver your baby."

A nurse is providing teaching about weight gain during pregnancy for a client who is a primigravida of normal pre-pregnancy weight. Which of the following statements should the nurse include?

"You should plan to gain 25 to 35 pounds during your pregnancy."

A nurse in a clinic is providing education to a client at 32 weeks of gestation who has pruritus gravidarum. Which of the following pieces of information should the nurse provide?

"You should slightly increase your exposure to sunlight."

A nurse is caring for a client who is at 26 weeks gestation and reports constipation. Which of the following responses by the nurse is appropriate?

"You should walk for at least 30 min every day."

A nurse is caring for a client who is at 35 weeks of gestation and is scheduled to undergo an amniocentesis. Which of the following statements should the nurse make?

"You will feel some mild discomfort during the procedure."

A nurse is teaching a client about using the Lamaze method to manage pain during labor. Which of the following pieces of information should the nurse include?

"You will learn how to prevent pain during labor by focusing your mind to control your breathing."

A nurse is teaching a client who is at 10 weeks gestation about an abdominal ultrasound in the first trimester. Which of the following pieces of information should the nurse include in the teaching?

"You will need to have a full bladder during the ultrasound."

A nurse in an outpatient setting is providing education for a client who is pregnant. Which of the following statements should the nurse include in the teaching?

"You will probably first notice your baby moving when you are around 20 weeks gestation."

A nurse is caring for a postpartum client 8 hr after delivery. Which of the following factors places the client at risk of uterine atony? (Select all that apply.)

- Magnesium sulfate infusion - Distended bladder - Prolonged labor

A nurse is caring for a client who is 8 hr postpartum and is experiencing hemorrhage. Which of the following actions should the nurse implement after notifying the provider? (Select all that apply.)

- Massage the fundus - Administer oxytocin with IV fluids - Insert an indwelling urinary catheter - Place the client in a lateral position with her legs elevated 30°

A nurse is performing a physical assessment of a full-term newborn and eliciting the Moro reflex. Which of the following movements are expected responses to this reflex? (Select all that apply.)

-Thumb and forefinger forming a "C" -Legs extending before pulling upward

A nurse is preparing to administer morphine oral solution 0.04 mg/kg to a newborn who weighs 2.5 kg. The amount available is morphine oral solution 0.4 mg/mL. How many mL should the nurse administer? (Fill in the blank with the numeric value only, round the answer to the nearest hundredth, and use a leading zero if applicable. Do not use a trailing zero.)

0.25

A nurse is providing teaching about calcium intake to a client who is breastfeeding. Which of the following is the recommended daily calcium intake for a client who is breastfeeding?

1,000 mg

A nurse is teaching the guardians of a newborn about the facility's safety measures. Which of the following pieces of information should the nurse include?

Check for a photo identification badge before allowing a nurse to remove the newborn from the room

A nurse is caring for a client who is at 39 weeks gestation and in active labor. Which of the following actions should the nurse include in the plan of care?

Check the cervix prior to analgesic administration

A nurse is caring for a client who is at 33 weeks of gestation and reports dark red vaginal bleeding and contractions that do not stop. Which of the following actions should the nurse take first?

Check the fetal heart tones

A nurse is preparing to provide umbilical cord care for a newborn 12 hours after delivery. Upon inspection, the nurse notes moderate bleeding from a blood vessel. Which of the following actions should the nurse take?

Check the integrity of the cord clamp

A nurse is providing discharge instructions for a client who had a cesarean birth 4 days ago. The client's hemoglobin level is 9.2 g/dL, and the provider has prescribed an iron supplement. Which of the following foods should the nurse recommend to help increase the client's iron intake?

Citrus fruit

A nurse is caring for a client during her first prenatal visit and notes that she is lactose-intolerant. Which of the following foods should the nurse include on a list of calcium sources for this client?

Collard greens

A nurse is assisting with an amniocentesis for a client who is Rh-negative. Which of the following actions should the nurse take following the procedure?

Administer immune globulin to the client to prevent fetal isoimmunization

A nurse is planning care for a client in labor who is positive for HIV. Which of the following actions should the nurse take after the baby is born?

Administer the hepatitis B vaccine prior to discharge

A nurse is preparing to administer routine medications to a newborn following birth. Which of the following actions should the nurse take?

Administer vitamin K in the newborn's thigh

A nurse is assessing a pregnant client at 26 weeks of gestation who reports an episode of dizziness after lying on her back on the couch. Which of the following actions should the nurse take?

Advise the client to lie on her side

A nurse is reviewing recent laboratory values during a prenatal visit for a client who is pregnant. The nurse notes a hemoglobin level of 10 g/dL. Which of the following actions should the nurse take?

Advise the client to start iron and vitamin C supplementation

A nurse is caring for a client who delivered a stillborn child. Which of the following actions should the nurse take?

Allow the parents to keep the child in their room for as long as they wish

A nurse is caring for a client who is scheduled to undergo an amniocentesis to assess fetal lung maturity. The client is G2P1 and at 36 weeks of gestation, and she has an O-positive blood type. Which of the following interventions should the nurse perform?

Apply an external fetal monitor to the client

While caring for a client who is in active labor, a nurse notes late decelerations on the fetal monitor. Which of the following actions should the nurse take?

Apply oxygen at 10 L/min via nonrebreather face mask

A nurse is caring for a client who is in the latent phase of labor and is experiencing low back pain. Which of the following actions should the nurse take?

Apply pressure to the client's sacral area during contractions

A nurse is caring for a client whose last menstrual period (LMP) began on July 8. Using Naegele's rule, what is the client's estimated date of birth (EDB)?

April 15

A nurse is caring for a client in the third trimester of pregnancy who is scheduled to undergo a non-stress test. Which of the following actions should the nurse take prior to the test?

Ask the client to drink a glass of orange juice

A nurse is assessing a client on the first postpartum day. Findings include the following: fundus firm and one fingerbreadth above and to the right of the umbilicus, moderate lochia rubra with small clots, temperature 37.3°C (99.2°F), and pulse rate 52/min. Which of the following actions should the nurse take?

Ask the client when she last voided

A nurse is caring for a client who is postpartum and is having difficulty voiding. Which of the following actions should the nurse take first?

Assist the client to the bathroom

A nurse is assessing a client who delivered vaginally 8 hours ago. The nurse notes that the client's fundus is 2 fingerbreadths above the umbilicus and has shifted to the left, and there is a large amount of lochia rubra on the perineal pad. Which of the following actions should the nurse take first?

Assist the client to the toilet

A nurse is planning care for a client who is pregnant and is Rh-negative. In which of the following situations should the nurse administer Rh(D) immune globulin?

At 28 weeks gestation

A nurse is assessing a client who missed 2 menstrual cycles and reports that she might be pregnant. Which of the following findings is a positive sign of pregnancy?

Auscultation of a fetal heart rate

The parents of a child with phenylketonuria (PKU) ask the nurse if their second unborn child could have the same condition. The nurse should base the response on which of the following inheritance patterns responsible for PKU?

Autosomal recessive

A nurse is caring for an infant who begins displaying manifestations of neonatal abstinence syndrome (NAS). Which of the following actions should the nurse take?

Avoid eye contact during feedings

A nurse is teaching a parent of a newborn about circumcision care. Which of the following instructions should the nurse include?

Avoid using diaper wipes on the site during diaper changes

A nurse is preparing to obtain a newborn's temperature. Which of the following methods should the nurse use?

Axillary

A nurse is assessing a client before administering the hepatitis B vaccine. Which of the following allergies should the nurse identify as a contraindication to receiving this vaccine?

Baker's yeast

A nurse is assessing a newborn who has a congenital diaphragmatic hernia. Which of the following findings should the nurse expect?

Barrel-shaped chest

A nurse is counseling a female client who expresses a desire to conceive in the near future. Which of the following dietary recommendations should the nurse make to prevent neural tube defects?

Begin taking a folic acid supplement

A nurse is providing teaching to the parents of a newborn about bottle-feeding. Which of the following instructions should the nurse include in the teaching?

Boil water for powdered formula for 1-2 min

A nurse in a prenatal clinic is performing telephone triage for several clients. Which of the following client reports should the nurse identify as an expected physiological adaptation to pregnancy?

Breast tenderness

A nurse is reviewing the plan of care before assuming the care of a newborn who is prescribed a hepatitis B vaccine, vitamin K, and an antiretroviral regimen. The plan of care indicates the newborn's mother is HIV-positive and plans to breastfeed. Which of the following findings should the nurse address with the newborn's interdisciplinary team?

Breastfeeding

A nurse is providing teaching about newborn care to the parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?

"I will place a hat on my baby's head prior to going outside."

A nurse is providing teaching to the parents of a newborn about home safety. Which of the following statements by the parents indicates an understanding of the teaching?

"I will place my baby on his back when putting him to sleep."

A nurse is teaching a client who is postpartum about keeping the newborn safe. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"I will purchase a firm mattress for the crib."

A nurse is caring for a client who experienced a fetal loss. When initiating communication with this client, which of the following statements should the nurse make?

"I'm here for you if you would like to talk."

A nurse is providing education for a pregnant client about symptoms that should be reported immediately to the provider. Which of the following client responses indicates an understanding of the teaching?

"If I notice that my eyes are puffy, I should call my provider."

A nurse is teaching a client who is pregnant about nonstress testing. Which of the following pieces of information should the nurse include?

"If the test is reactive, that means your baby's heart rate is healthy."

A nurse is talking with a client during her initial prenatal visit. The client reports a history of trisomy 13 syndrome in her family and is concerned her fetus might be at risk. Which of the following statements should the nurse provide?

"If you sign an informed consent form, we can perform genetic screening to see if your baby has this disorder."

A nurse is teaching a sibling class for a group of expectant parents and their older children. Which of the following statements should the nurse include to facilitate sibling adaptation?

"Involve the siblings in decorating your newborn's room."

The guardian of a 3-day-old female newborn tells the nurse that he noticed a small amount of blood-tinged mucus discharge on the newborn's labia. Which of the following responses should the nurse make?

"The blood-tinged mucus is a result of pseudomenstruation."

A nurse is assessing a 2-day-old newborn and notes an egg-shaped, edematous, bluish discoloration that does not cross the suture line. Which of the following pieces of information should the nurse provide to the mother when she asks about this finding?

"This will resolve in 3 to 6 weeks without treatment."

A nurse is caring for a client who asks, "How will I know if I'm having true or false labor contractions?" Which of the following responses should the nurse make?

"True contractions will begin irregularly and then become regular in timing."

A nurse is performing a routine prenatal examination of a client who is in the second trimester. The client reports backaches with no other symptoms and refuses medication. Which of the following responses should the nurse make?

"Try pelvic tilt exercises."

A nurse is providing education about continuous heparin therapy for a client who is 18 hours postpartum and has developed a deep vein thrombosis (DVT). Which of the following statements should the nurse include in the teaching?

"Use a soft toothbrush to brush your teeth gently."

A nurse at a family-planning clinic is preparing to teach a class about how to use a diaphragm. Which of the following pieces of information should the nurse plan to include in the teaching?

"Use spermicidal jelly whenever you use your diaphragm."

A nurse is teaching a client who is breastfeeding about strategies for preventing mastitis. Which of the following instructions should the nurse include?

"Use your finger to release suction after feeding."

A nurse is providing teaching about exercise to a client who is pregnant. Which of the following pieces of information should the nurse include?

"Vigorous exercises should be limited and should not be performed in hot, humid weather."

A nurse is caring for a client who is in labor. The client questions the application of an internal fetal scalp monitor. Which of the following responses should the nurse provide?

"We need to observe your baby more closely."

A nurse is teaching a prenatal class for a group of antepartum clients. Which of the following pieces of information should the nurse include about the hepatitis B immunization?

"We will need your consent prior to administering the vaccine."

A nurse is admitting a client who is in post-term labor. Which of the following statements should the nurse identify as the priority?

"When my water broke, it was not clear."

A nurse is caring for a client who has trichomoniasis and a prescription for metronidazole. Which of the following instructions should the nurse provide to the client about the treatment plan?

"You and your partner need to take the medication and use a condom during intercourse until cultures are negative."

A nurse is assessing a pregnant client who is at 38 weeks gestation. The client reports that her breathing has become easier but notes an increased frequency of urination. The nurse should document this occurrence as which of the following?

Lightening

A nurse is assessing a newborn for congenital hip dysplasia. Which of the following findings should the nurse expect?

Limited abduction of a hip

A nurse is monitoring a client who is receiving spinal anesthesia. The nurse should identify which of the following findings as a complication of the infusion?

Maternal hypotension

A nurse is performing a physical assessment of a newborn. Which of the following actions should the nurse take?

Measure the circumference of the newborn's head with a tape measure just above the eyebrows

A nurse is assessing a client who is 3 days postpartum. When examining the client's uterus, which of the following techniques should the nurse use?

Measure the height of the fundus in fingerbreadths in relation to the umbilicus

A nurse is caring for a client who requests an intrauterine device (IUD) for contraception. Which of the following findings is a contraindication for this device?

Menorrhagia

A nurse is caring for a client who has a soft uterus and increased lochial flow. Which of the following medications should the nurse plan to administer to promote uterine contractions?

Methylergonovine

A nurse is providing teaching about formula feeding to the guardian of a newborn. Which of the following pieces of information should the nurse include?

Mix 1 scoop of powdered formula with 2 oz of water

A nurse is planning care for a client who is postpartum and has cardiac disease. For which of the following prescriptions should the nurse seek clarification?

Monitor the client's weight weekly

A nurse is preparing to administer an IV infusion of oxytocin for labor induction to a client who is at 41 weeks of gestation. Which of the following actions should the nurse plan to take?

Monitor the fetal heart rate every 15 minutes initially

A nurse is assessing a newborn. For which of the following findings should the nurse notify the provider?

Mottling

A nurse is assessing a newborn. Which of the following findings suggests the newborn is post-mature?

Nails extending over finger

A nurse is assessing a newborn. Which of the following findings should the nurse immediately report to the provider?

Nasal flaring

A nurse is assessing a client who reports that she might be pregnant. Which of the following findings should the nurse identify as a presumptive sign of pregnancy?

Nausea in the morning

A nurse is assessing a 7-month-old infant during a well-child visit and notes the presence of a full Moro reflex. For which of the following conditions should the nurse screen the infant?

Neurological disorder

A nurse is assessing a client who is at 30 weeks of gestation and has gestational hypertension. Which of the following findings should the nurse identify as an indication that the client needs a biophysical profile?

Nonreactive non-stress test

A nurse is caring for a client at 36 weeks gestation who has pre-eclampsia. Which of the following findings should the nurse identify as the priority?

Nonreactive nonstress test

A nurse is assessing a postpartum client and observes a steady trickle of bright red blood from the client's vagina. The uterus is palpated as firm, midline, and located 1 cm below the umbilicus. Which of the following actions should the nurse take?

Notify the provider

A nurse is providing care for a pregnant adolescent who is at 12 weeks gestation and verbalizes a fear of gaining weight during pregnancy. Which of the following actions should the nurse take?

Provide examples of how eating well will help maintain a healthy weight during pregnancy

A nurse is providing education for the parent of a premature infant on interventions to promote optimal development. Which of the following actions should the nurse instruct the parent to perform?

Provide kangaroo care for the infant

A nurse is teaching a client who is at 10 weeks gestation about self-care management for common discomforts during pregnancy. Which of the following instructions should the nurse include?

Consume frequent snacks to decrease episodes of nausea

A nurse is assessing a 12-hour-old newborn and notes a respiratory rate of 44/min with shallow respirations and periods of apnea lasting up to 10 sec. Which of the following actions should the nurse take?

Continue routine monitoring

A nurse is caring for a client who is in the first stage of labor. Which of the following findings should the nurse identify as a cause for concern?

Contractions lasting 100 seconds

A nurse receives a report for a client who is in labor and is experiencing contractions that are 4 min apart. Which of the following patterns should the nurse expect on the fetal monitor tracing?

Contractions that last for 60 sec each with a 3 min rest between contractions

A nurse is discussing contraceptive choices with a client who has a history of thrombophlebitis. Which of the following methods of contraception should the nurse recommend?

Copper intrauterine device

A nurse is caring for a client who is in active labor and whose birth plan requests only nonpharmacological pain relief strategies. Which of the following strategies should the nurse offer as a form of cutaneous stimulation?

Counter-pressure

A nurse is caring for a client who is 24 years old and at 13 weeks of gestation. The client's history includes a BMI of 31 prior to pregnancy, a prior post-term delivery, and a newborn birth weight of 4,167.38 g (9 lb 3 oz). Which of the following laboratory values should the nurse expect to collect?

HbA1c

A nurse is assessing a newborn. Which of the following findings should the nurse report to the provider?

Head circumference 28 cm (11 in)

A nurse is caring for a client labor who has an epidural for pain relief. Which of the following is a complication of the epidural block?

Hypotension

A nurse is preparing to administer naloxone to a newborn. Which of the following conditions can require administration of this medication?

IV narcotics administered to the mother during labor

An adolescent reports abdominal cramping due to dysmenorrhea. Which of the following analgesics should the nurse expect the provider to prescribe?

Ibuprofen

A nurse is monitoring a newborn for indications of septic shock. Which of the following findings should the nurse expect if the newborn develops this complication?

Decreased blood pressure

A nurse is assessing a client who is at 26 weeks of gestation and has mild preeclampsia. Which of the following findings should the nurse report to the provider?

Deep tendon reflexes 4+

A nurse is caring for a client who is in labor. The nurse decides to switch from intermittent auscultation to continuous fetal monitoring. Which of the following data can only be obtained from continuous electronic fetal monitoring?

Determination of variability

A charge nurse is providing teaching for a newly hired nurse about the potential side effects of an epidural anesthetic for a laboring client. Which of the following effects should the charge nurse include in the teaching?

Impaired placental perfusion

A nurse is caring for a client in the early stage of labor who has preeclampsia with severe features. Which of the following interventions should the nurse perform?

Implement seizure precautions

A nurse is providing teaching for new parents about formula feeding. Which of the following instructions should the nurse include?

Discard opened cans of formula after 48 hr refrigeration

A nurse is assessing a newborn. Which of the following findings should the nurse identify as an indication of recent maternal heroin use?

Incessant crying

A nurse is caring for a client who is in labor and has received epidural analgesia. The client's blood pressure is 88/50 mmHg, and the fetal heart tracing shows late decelerations. Which of the following actions should the nurse take?

Increase the rate of the primary IV infusion

A nurse is caring for a client in labor and observes a pattern of early decelerations on the fetal monitor. Which of the following actions should the nurse take?

Document the findings and continue to monitor

A nurse is assessing a client who is at 36 weeks of gestation. Which of the following manifestations should the nurse recognize as a potential prenatal complication and report to the provider?

Double vision

A charge nurse is teaching newly licensed nurses about teratogens that affect fetal development. The nurses should recognize that which of the following is an example of a teratogen?

Drinking alcohol during pregnancy

A nurse is caring for a newborn immediately following birth. Which of the following actions should the nurse take first?

Dry the newborn

A nurse is caring for a client who is 2 hours postpartum and is exhibiting signs of hypovolemic shock. Which of the following actions should the nurse take?

Elevate the client's legs to a 30° angle

A nurse is reviewing the laboratory report for a client with suspected HELLP syndrome. Which of the following findings should the nurse report to the provider as an indication of this disorder?

Elevated liver enzymes

A nurse is reviewing the electronic medical record of a newborn. Which of the following maternal factors may increase the risk of pathologic hyperbilirubinemia in the newborn?

Infection

A nurse is providing teaching to the parents of a newborn about how to care for his circumcision at home. Which of the following instructions should the nurse include in the teaching?

Encourage non-nutritive sucking for pain relief

A nurse in a labor and delivery unit is caring for a client who is in the second stage of labor. Which of the following actions should the nurse take?

Encourage the client to frequently change positions.

A postpartum nurse is caring for a client who reports abdominal cramping. Which of the following actions should the nurse take?

Encourage the client to interact with the newborn

A nurse is planning care for a newborn who requires phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan of care?

Ensure the newborn's eyes are closed before applying the eye shield

A nurse is providing teaching about breastfeeding to a client who is 4 hours postpartum. Which of the following pieces of information should the nurse include?

Ensure the newborn's mouth covers the nipple and areola

A nurse is caring for a newborn directly after birth. Which of the following medications should the nurse administer to the newborn within 1-2 hr of delivery?

Erythromycin ophthalmic ointment

A nurse is assessing a client who is pregnant and reports increased nasal stuffiness. The nurse should inform the client that which of the following hormones is responsible for this discomfort?

Estrogen

A nurse is caring for a client who is in labor. Which of the following methods will determine the frequency of the client's contractions?

Evaluating the time from the beginning of a contraction to the beginning of the next contraction

A nurse is caring for a newborn who has neonatal abstinence syndrome.Which of the following clinical findings should the nurse expect?

Exaggerated reflexes

A nurse is assessing the respiratory status of a newborn who was born 2 hours ago. Which of the following findings should the nurse identify as a manifestation of respiratory distress?

Expiratory grunting

A nurse is assessing a newborn at birth who was delivered at 32 weeks gestation. Which of the following findings should the nurse anticipate?

Extended extremities

A nurse is teaching a client who is at 12 weeks gestation about manifestations of potential complications that she should report to her provider. Which of the following pieces of information should the nurse include in the teaching?

Facial swelling

A nurse is teaching a client with pre-eclampsia who is scheduled to receive magnesium sulfate via continuous IV infusion about expected adverse effects. Which of the following adverse effects should the nurse include in the teaching?

Feeling of warmth

A nurse is caring for a client who is in labor and is receiving an infusion of oxytocin. The nurse should monitor the client for which of the following potential adverse effects?

Fetal asphyxia

A nurse is reviewing the medical record of a client at 39 weeks gestation who has polyhydramnios. Which of the following findings should the nurse expect?

Fetal gastrointestinal anomaly

A nurse is caring for a client who is in labor. Which of the following assessment findings should the nurse report to the provider?

Fetal heart rate baseline of 90 bpm

A nurse is providing care to a client who is in labor and experienced a spontaneous rupture of membranes. Which of the following findings requires intervention by the nurse?

Fetal heart rate decreased by 15/min

A nurse is caring for a client who states, "I think I am pregnant." Which of the following findings should the nurse identify as a positive sign of pregnancy?

Fetal heart tones auscultated by Doppler

A nurse is reviewing the provider's admission orders for a client who is at 37 weeks of gestation and is HIV positive. Which of the following orders should the nurse clarify with the provider?

Fetal scalp electrode

A nurse in labor and delivery is teaching a newly licensed nurse about performing the McRoberts maneuver to relieve shoulder dystocia. Which of the following pieces of information should the nurse include?

Flex the client's legs apart and raise her knees to her abdomen

A nurse in an antepartum clinic is caring for a client who is at 24 weeks gestation. Which of the following findings should the nurse report to the provider?

Frequent headaches

A nurse is caring for a newborn who was born to a client with a narcotic use disorder. Which of the following nursing actions is contraindicated in the care of this newborn?

Frequent stimulation

A nurse is caring for a client who is scheduled to receive a continuous IV infusion of oxytocin following a vaginal birth. Which of the following assessment findings should the nurse monitor to evaluate the effectiveness of the medication?

Fundal consistency

A nurse is caring for a client who is pregnant and has a rupture of membranes. The nurse notes the presence of meconium-stained fluid. Which of the following actions should the nurse take?

Gather equipment for neonatal resuscitation

A nurse is assessing a newborn who is 2 hr old. Which of the following findings should the nurse report to the provider?

Generalized petechiae

A nurse is reviewing risk factors for postpartum depression with newly licensed nurse> Which of the following risk factors should the nurse include?

Gestational Diabetes

A nurse is caring for a newborn. The nurse should obtain informed consent before taking which of the following actions?

Giving the hepatitis B vaccine

A nurse is reviewing the laboratory findings for 4 clients. Which of the following infections should be reported to the public health department?

Gonorrhea

A nurse is providing education to a female client of child-bearing age. The nurse should state that which of the following structures expels the mature ovum?

Graafian follicle

A nurse is planning care for a client who is at 35 weeks gestation. Which of the following laboratory tests should the nurse obtain?

Group B streptococcus ß-hemolytic

A nurse is caring for a client who is using patterned-paced breathing during the first stage of labor. The client reports a lightheaded feeling and tingling of the fingers. Which of the following actions should the nurse take?

Have the client breathe into a paper bag

A nurse at a prenatal clinic is assessing an adult client who had genital cutting performed as a child as part of her cultural practices. The nurse notes the client's clitoris and labia minora were removed, and she has scarring in the vaginal area. Which of the following actions should the nurse take?

Inform the client that giving birth vaginally might not be possible

A nurse is reviewing laboratory results for a client who is at 37 weeks gestation. The nurse notes that the client is rubella non-immune, is positive for group A beta-hemolytic streptococcus, and has a blood type of O negative. Which of the following actions should the nurse take?

Instruct the client to obtain a rubella immunization after delivery

A nurse is caring for a client in active labor whose fetus is in a persistent occiput posterior position. Which of the following actions should the nurse take to promote rotation of the fetal head?

Instruct the client to squat during contractions

A nurse is teaching a group of clients who are pregnant about vitamin K for newborns. Vitamin K helps prevent which of the following conditions in a newborn?

Intracranial hemorrhage

A nurse is planning care for a newborn who was born at 30 weeks gestation. The nurse should plan to assess the newborn for which of the following potential complications associated with prematurity?

Intraventricular hemorrhage

A nurse is providing nutritional counseling for a client who is pregnant. Which of the following nutrients should the nurse instruct the client to increase in her daily diet?

Iron

A nurse is caring for a client who is pregnant and whose last menstrual period (LMP) began on April 8. Using Naegele's rule, which of the following dates would be the client's estimated date of birth (EDB)?

January 15

A nurse is assessing a newborn 1 hr after birth. Which of the following findings should the nurse report to the provider?

Jaundice of the sclera

A nurse in a clinic is assessing a client who is at 13 weeks of gestation and has hyperemesis gravidarum. Which of the following findings should the nurse identify as the priority?

Ketones 2+

A nurse is assisting with monitoring the fetal heart rate tracings of a client who is in labor. Which of the following findings should the nurse report to the provider?

Late decelerations with fetal bradycardia

A nurse is caring for a client who is experiencing prolonged labor. Which of the following fetal monitoring results indicates fetal compromise?

Late decelerations with fetal bradycardia

A nurse on the antepartum unit is caring for a client who is at 28 weeks gestation and reports dizziness when lying on her back. Into which of the following positions should the nurse assist the client?

Lateral

A nurse is caring for a client in the latent stage of labor who is reporting a pain level of 4 on a scale of 1 to 10. Which of the following actions should the nurse take?

Lead the client in relaxation breathing techniques

A nurse is using Naegele's rule to determine the estimated date of birth (EDB) for a client whose first day of her last menstrual period was February 2, 2018. The nurse should identify which of the following as the client's EDB?

November 9, 2018

A nurse at a prenatal clinic is assessing an adolescent who is pregnant and is visiting the clinic for the first time. Which of the following factors is the nurse's priority to evaluate?

Nutritional status

A nurse is assessing a 12-hour-old newborn notes mild jaundice of the face and trunk. Which of the following actions should the nurse take?

Obtain a stat prescription for a bilirubin level

A nurse is admitting a client who is in labor and experiencing moderate bright red vaginal bleeding. Which of the following actions should the nurse take?

Obtain blood samples for baseline laboratory values

A nurse is calculating a pregnant client's estimated date of delivery using Naegele's rule. The client's last menstrual period started on January 20. Which of the following is the client's expected date of delivery?

October 27

A nurse is caring for a client who is nulliparous and experiencing hypertonic uterine dysfunction. An assessment indicates 3 cm dilation. Which of the following actions should the nurse take?

Offer the client hydrotherapy

A nurse is caring for a client who is nulliparous and experiencing hypertonic uterine dysfunction. An assessment indicates 3 cm dilation. Which of the following actions should the nurse take?

Offer the client hydrotherapy

A nurse is assessing a postpartum client who has preeclampsia and notes a boggy uterus and excessive uterine bleeding. The nurse should plan to administer which of the following medications?

Oxytocin

A nurse is caring for a client who believes she may be pregnant. Which of the following findings should the nurse identify as a positive sign of pregnancy?

Palpable fetal movement

A nurse in a labor and delivery unit is preparing to teach a newly licensed nurse about intermittent auscultation of the fetal heart rate. Which of the following interventions should the nurse include?

Palpate and count the maternal radial pulse while listening to the fetal heart rate

A nurse is caring for a client who had a precipitous delivery. Which of the following assessments is the priority during the fourth stage of labor?

Palpating the client's fundus

A nurse is caring for a client who has clinical manifestations of an ectopic pregnancy. Which of the following findings is a risk factor for an ectopic pregnancy?

Pelvic inflammatory disease (PID)

A nurse is providing care for a client who is in the second stage of labor. The fetal heart tracing indicates multiple variable decelerations. Which of the following actions should the nurse take?

Prepare an amnioinfusion

A nurse is caring for a client in active labor who has meconium staining of the amniotic fluid. The nurse notes a reassuring fetal heart rate (FHR) tracing from the external fetal monitor. Which of the following actions should the nurse perform?

Prepare equipment needed for newborn resuscitation

A nurse is caring for a pregnant client who is at 37 weeks of gestation and who had a biophysical profile with a total score of 4. Which of the following actions should the nurse anticipate taking?

Prepare for delivery of the infant

A nurse is caring for a client who is attempting a trial of labor (TOL) after several cesarean births. The client reports a sudden onset of constant abdominal pain, and the nurse observes a prolonged deceleration on the fetal heart rate tracing. Which of the following actions should the nurse take?

Prepare the client for an emergency cesarean delivery

A nurse is caring for a client who is receiving IV oxytocin for the induction of labor and notes repetitive early decelerations on the electronic fetal heart rate (FHR) tracing. Which of the following actions should the nurse take?

Re-evaluate the FHR tracing in 15 minutes

A nurse is caring for a client who is in active labor and receiving an oxytocin infusion. The nurse notes tachsystole with a category 1 fetal heart rate tracing. Which of the following actions should the nurse take?

Reposition the client in a side-lying position and continue to monitor

A nurse is planning care for a newborn who has hyperbilirubinemia and a new prescription for phototherapy. Which of the following interventions should the nurse include in the plan?

Reposition the newborn every 3 hours

A nurse in a clinic is caring for a client who is pregnant and reports a last menstrual period (LMP) that began on December 7. Which of the following dates would be the client's estimated date of birth (EDB)?

September 14

A postpartum nurse is providing care for a client who is breastfeeding and has a perineal hematoma. The nurse should recommend that the client use which of the following breastfeeding positions?

Side-lying

A nurse is assessing a client who has hyperemesis gravidarum. Which of the following findings should the nurse expect?

Presence of ketones in the urine

A nurse is reviewing the laboratory values of a client who is pregnant and has a low progesterone level. Which of the following complications should the nurse expect?

Preterm labor

A nurse is providing teaching for a client about hormonal changes during pregnancy. The nurse identifies that which of the following hormones plays a key role in preventing miscarriage?

Progesterone

A nurse is assessing a client who is postpartum following a vacuumassisted birth. For which of the following findings should the nurse monitor to identify a cervical laceration?

Slow trickle of bright vaginal bleeding and a firm fundus

A nurse is caring for a client who is in labor and is reporting intense pain during contractions. The client has no previous knowledge of nonpharmacological comfort measures. Which of the following nursing interventions should the nurse implement?

Slow-paced breathing

A nurse is performing an initial physical assessment of a newborn following a vaginal birth. Which of the following findings should the nurse report to the provider?

Small, pinpoint, reddish-purple spots on the chest

A nurse is providing education about newborn skin care for a group of new parents. Which of the following instructions should the nurse include?

Sponge bathe the newborn every other day

A nurse is caring for a client who is in labor and is receiving IV oxytocin. The nurse notes contractions lasting 3 min each. What action should the nurse take?

Stop the oxytocin infusion

A nurse is teaching a client about physiological changes that can occur with menopause. Which of the following changes should the nurse include?

Stress incontinence

A nurse is planning educational sessions for clients in a childbirth class. Which of the following findings should the nurse plan to instruct the clients to report immediately?

Swelling of the face and fingers

While assessing a client who is in the fourth stage of labor, the nurse suspects bladder distention. Which of the following findings should the nurse anticipate with bladder distention?

The bladder fluctuates with palpation.

A nurse is caring for a client who experienced a spontaneous rupture of membranes and has prolonged decelerations on the fetal monitor. Which of the following conditions should the nurse expect?

Prolapsed umbilical cord

A nurse is planning care for a client in active labor whose fetus is in an occipital brow presentation. Which of the following complications should the nurse anticipate as a result of this fetal presentation?

Prolonged labor

A nurse is assessing a client who is in the first stage of labor and has preeclampsia. Which of the following findings should the nurse expect?

Proteinuria

A nurse is caring for a client who is postpartum and reports that her episiotomy incision is pulling and stinging. Which of the following actions should the nurse take?

Provide a sitz bath with warm water for the client

A nurse is assessing a client who is at 34 weeks gestation and has a cardiac disorder. The nurse should notify the provider about which of the following assessment findings?

The client reports a frequent cough.

A nurse is caring for a client who is scheduled to receive intravenous oxytocin for the induction of labor. The client has a Bishop score of 10. Which of the following findings should the nurse expect?

The client will experience a successful induction of labor

A nurse is performing an admission assessment of a client who just arrived at the labor and delivery unit. Which of the following findings should the nurse identify as the priority?

The fetal heart rate is 90/min.

A nurse is assessing a client at 27 weeks of gestation. The client has placenta previa and reports vaginal bleeding. Which of the following additional manifestations should the nurse expect?

The fundal height measures greater than gestational age.

A nurse at a clinic is preparing to teach the process of involution to a group of antenatal clients. Which of the following information should the nurse provide?

The fundus is not palpable abdominally at 2 weeks postpartum

A nurse is assessing the Moro response of a newborn. Which of the following findings should the nurse expect?

The legs move in a similar pattern of response to the arms

A nurse is performing a physical assessment of a male newborn. Which of the following findings should the nurse report to the provider?

There is decreased abdominal movement with breathing

A nurse is teaching the guardian of a newborn about caring for the newborn's umbilical cord. For which of the following reasons should the nurse instruct the guardian to avoid using antimicrobial agents on the cord?

They can cause delayed cord separation.

A nurse is testing the reflexes of a newborn to assess neurological maturity. Which of the following reflexes is the nurse assessing by quickly and gently turning the newborn's head to one side?

Tonic neck

A nurse is caring for a client in labor whose cervix is dilated to 9 cm. She is experiencing strong contractions every 2 min lasting 75 sec. The nurse should recognize that the client is in which of the following phases of stages of labor?

Transition phase of first stage

A nurse is assessing a client who is suspected of having hyperemesis gravidarum. Which of the following laboratory tests should the nurse check first?

Urine ketones

A nurse is assessing a client who is receiving morphine via a patientcontrolled analgesia (PCA) pump following a cesarean birth. Which of the following findings should the nurse report to the provider?

Urine output 20 mL/hr

A nurse is caring for a client who is at 16 weeks gestation and has severe iron-deficiency anemia. The provider prescribes an injection of iron dextran IM. Which of the following methods should the nurse use to administer the medication?

Use a 20-gauge needle and administer the medication using the Ztrack method

A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin level. Which of the following actions should the nurse take?

Use a photometer to monitor the lamp's energy

A nurse is caring for a client in the third trimester of pregnancy who reports difficulty sleeping. Which of the following instructions should the nurse provide?

Use additional pillows to support extremities and abdomen.

A nurse is caring for a client at 34 weeks gestation who presents with vaginal bleeding. Which of the following assessments will indicate whether the bleeding is caused by placenta previa or an abruptio placenta?

Uterine tone

A nurse is caring for a client at 39 weeks gestation who is in the active phase of labor. The nurse observes late decelerations in the fetal heart rate (FHR). Which of the following findings should the nurse identify as the cause of late decelerations?

Uteroplacental insufficiency

A nurse is teaching a client who is at 30 weeks gestation about warning signs of complications that she should report to her provider. Which of the following findings should the nurse include in the teaching?

Vaginal bleeding

A nurse is caring for a client who is in labor. A vaginal examination reveals the following findings: 2 cm, 50%, +1, right occiput anterior (ROA). Based on this information, which of the following fetal positions should the nurse document in the medical record?

Vertex

A nurse is reinforcing teaching about nutritional requirements during lactation for a client who is planning to breastfeed. Which of the following nutrients should the client increase during lactation?

Vitamin C

A nurse is preparing to perform a heel stick on a newborn. Which of the following actions should the nurse take?

Warm the heel with a warm washcloth prior to the procedure

A nurse is providing teaching about newborn baths to a client who is 2 days postpartum. Which of the following pieces of information should the nurse include?

Wash the newborn's face with plain warm water

A postpartum nurse is caring for a client who has developed hemorrhagic shock. Which of the following manifestations should the nurse expect?

Weak and irregular pulse

A nurse is determining an Apgar score for a newborn who was born 1 minute ago. For which of the following findings should the nurse assign a score of 1?

Weak cry

A nurse is monitoring a newborn who is receiving phototherapy. The nurse should identify which of the following findings as requiring intervention?

Weight loss 12% of birth weight

A nurse is preparing to massage the fundus of a client who is postpartum and experiencing uterine atony. In what order should the nurse take the following actions when performing a fundal massage? (Move the steps into the box on the right, placing them in order of the performance. Use all the steps.)

ask the client to lie on her back with her knees flexed. place a hand just above the client's symphysis pubis. position a hand around the top of the client's uterus. rotate the upper hand to massage the client's uterus. use slight downward pressure to compress rh client's fundus.

A nurse enters a postpartum client's room and notices many visitors in the room, conversing loudly and taking turns holding the newborn. The newborn intermittently cries and attempts to suck on her hand. After a few minutes, the newborn quiets, stares, and turns her head away when someone talks to her. What teaching should the nurse provide for this family?

The newborn would benefit from skin-to-skin contact in a quiet environment.

A nurse is assessing a client who is 2 days postpartum. In which of the following locations should the nurse expect to locate the client's fundus?

3 cm below the umbilicus

A nurse is caring for a client who had a vaginal delivery 24 hours ago. Which of the following findings should the nurse report to the provider?

3+ deep tendon reflexes

A nurse is assessing a client who is at 35 weeks of gestation and has preeclampsia without severe features. Which of the following findings should the nurse identify as the priority?

480 mL urine output in 24 hr

A nurse is caring for a client who is pregnant with a male child and expresses concern to the nurse about the possibility of the child having hemophilia. The client is a carrier of the gene mutation for this condition. Which of the following percentages represents the chance that the child will have this disorder?

50%

A nurse is assessing a newborn 1 min after birth and notes a heart rate of 136/min and respiratory rate of 36/min. The newborn has well-flexed extremities, responds to stimuli with a cry, and has blue hands and feet. Which Apgar score should the nurse assign to the newborn?

9

A nurse is caring for a client who is 12 hr postpartum. Which of the following interventions should the nurse implement?

Administer ferrous sulfate orally

A nurse is providing teaching to a client who is planning to breastfeed her newborn. Which of the following statements by the client indicates an understanding of the teaching?

"My baby may sometimes feed every hour for several hours in a row."

A nurse is teaching a prenatal class about nonpharmacological comfort measures during labor. Which of the following statements should the nurse identify as an indication that the instructions have been understood?

"My baby will be monitored with a Doppler device during hydrotherapy."

A nurse is caring for a client who is at 34 weeks gestation and has a prescription for terbutaline for preterm labor. Which of the following statements by the client is the priority?

"My heart feels like it is racing."

A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following statements should the nurse include?

"Notify your provider if you notice cracking on your nipples."

A nurse is caring for a client who is in the first trimester of pregnancy and asks how to manage heartburn. Which of the following responses should the nurse make?

"Reduce the amount of food you eat during meals."

A nurse is teaching a client who is in the third trimester of pregnancy and has herpes genitalis. Which of the following instructions should the nurse include?

"Talk with your doctor about a prescription for acyclovir to treat your symptoms."

A community health nurse is planning care for 4 high-risk newborns who were discharged yesterday. Which of the following newborns should the nurse plan to care for first?

A 4-day-old newborn who has an elevated bilirubin level and requires phototherapy

A nurse is caring for several clients. Which of the following clients should the nurse identify as a candidate for oral contraceptives?

A client who is breastfeeding a 7-month-old infant

A nurse in the labor and delivery suite is planning care for a group of 4 clients. Which of the following clients should the nurse see first?

A client who is in active labor and has late decelerations on the fetal heart monitor strip

A nurse is assisting with fetal heart monitoring during labor for a client who is at 40 weeks of gestation. The nurse should identify that which of the following findings on the fetal monitoring tracing requires intervention?

A fetal heart rate of 180/min for 15 minutes

A nurse is caring for 4 newborns. Which of the following newborns is at the greatest risk of hypoglycemia?

A newborn who is large for gestational age

A nurse in a newborn nursery has received reports on 4 newborns. Which of the following newborns should the nurse identify as requiring intervention?

A newborn whose axillary temperature is 36.1°C (96.9°F)

A nurse at a prenatal clinic is caring for a client who suspects she may be pregnant and asks the nurse how the provider will confirm her pregnancy. Which of the following laboratory tests will be used to confirm this client's pregnancy?

A urine test for the presence of human chorionic gonadotropin

A provider tells a client at 12 weeks gestation who practices Hinduism that she needs more protein in her diet and suggests eating more meat. After the provider leaves the examination room, the client tells the nurse that eating animal products will cause her to miscarry. Which of the following responses should the nurse make?

"Let's discuss other foods that are also high in protein that you could substitute for meat."

A nurse is caring for a client who is in labor and asks her partner to perform effleurage. The client has on a monitor belt for electronic fetal monitoring. Which of the following instructions should the nurse provide to the nurse provide to the client's partner?

"Lightly stroke the upper thighs."

A nurse is providing education to a client who is 4 weeks postpartum and is breastfeeding. The client asks about expected weight loss. Which of the following responses should the nurse make?

"Losing 2.2 pounds each month would be acceptable."

A nurse is teaching a client who had a vacuum-assisted vaginal delivery. Which of the following statements should the nurse identify as an indication that the client understands the information?

"My baby has a higher risk of developing jaundice."

A nurse is providing postpartum discharge teaching to a client who is nonlactating about breast discomfort relief measures. Which of the following pieces of information should the nurse include?

"Place fresh cabbage leaves on your breasts."

A nurse is providing teaching to a client who is postpartum and does not plan to breastfeed her newborn. Which of the following instructions should the nurse include in the teaching?

"Place ice packs on your breasts."

A nurse is caring for an adolescent who is in the second trimester of pregnancy. The client states, "I've gotten used to the idea of this pregnancy. It will be fun to have a little baby around the house." Which of the following is the appropriate response by the nurse?

"Tell me how you think your life will be after the baby is born."

A nurse is providing care to a client who is 2 hours postpartum and is receiving an oxytocin IV. The client asks the nurse, "Why is there so little bleeding?" Which of the following responses should the nurse make?

"The bleeding is minimal until I discontinue your IV medication."

A nurse is caring for a client who is at 20 weeks gestation. The client asks the nurse what the baby looks like at this point. Which of the following answers by the nurse provides an accurate response?

"The fetus resembles a human."

A nurse is teaching a client who is at 8 weeks gestation and has a uterine fibroid about potential effects of the fibroid during pregnancy. Which of the following pieces of information should the nurse include?

"The fibroid can increase the risk of postpartum hemorrhage."

A client at a routine prenatal care visit asks the nurse if developing vaginal yeast infections is common during pregnancy. Which of the following responses should the nurse make?

"The hormonal changes of pregnancy alter the acidity of the vagina, making yeast infections more common."

A nurse is caring for a newborn who has a prescription for phototherapy. The mother asks why the newborn needs to lay under a special light. Which of the following responses should the nurse make?

"The light will help lower your baby's bilirubin level."

A nurse is caring for a client who had pelvic measurements recorded by the provider. The client asks, "Since my pelvis is gynecoid, will I be able to deliver vaginally?" Which of the following responses should the nurse make?

"The shape of your pelvis is ideal for vaginal childbirth."

A nurse is speaking with an expectant father who says that he feels resentful of the added attention others are giving to his wife since the pregnancy was announced several weeks ago. Which of the following responses should the nurse make?

"These feelings are common for expectant fathers in early pregnancy."

A nurse is caring for a primigravid client who is at 8 weeks gestation with twins. The client states that even though she and her husband planned this pregnancy, she is experiencing ambivalent feelings about it. Which of the following responses should the nurse make?

"These feelings are quite normal at the beginning of pregnancy."

A postpartum nurse is caring for a client who reports excessive sweating during the first night after delivery. Which of the following statements should the nurse make?

"This is a source of your fluid loss after delivery."

A nurse is preparing to administer meperidine hydrochloride to a client who is in labor. Which of the following statements should the nurse make to the client?

"This medication can make you sleepy."

A nurse is preparing a client who is in labor for the insertion of an intrauterine pressure catheter. The client asks why this type of monitoring is needed. Which of the following responses should the nurse make?

"This type of monitoring will allow us to measure the intensity of your contractions."

A nurse in a clinic is providing teaching to a client who is at 37 weeks of gestation and is scheduled for an external cephalic version. Which of the following statements should the nurse make?

"You will receive a medication to relax your uterus prior to the procedure."

A nurse is providing discharge teaching to the parent of a newborn. Which of the following statements should the nurse include in the teaching?

"Your baby should be rear-facing in a car seat until 2 years of age."

A nurse is providing teaching for a postpartum client who is breastfeeding. Which of the following pieces of information should the nurse include in the teaching?

"Your milk supply will noticeably increase in volume around the third or fourth day after delivery."

A nurse is providing teaching to a client who has come to the familyplanning clinic requesting an intrauterine device (IUD). Which of the following pieces of information should the nurse provide the client?

"Your risk for ectopic pregnancy increases with an IUD."

A nurse is caring for a newborn who weighs 4 lb. How many kilograms does the newborn weigh? (Fill in the blank with the numeric value only, round the answer to the nearest tenth, and use a leading zero if applicable. Do not use a trailing zero.)

1.8

A nurse is caring for a newborn who is premature at 30 weeks gestation. Which of the following findings should the nurse expect?

Abundant lanugo

A nurse in a provider's office is caring for a client who is in the first trimester of pregnancy. Which of the following psychological tasks should the nurse expect the client to accomplish during this trimester?

Accepting the pregnancy

A nurse is planning care for a client who has a prescription for oxytocin. Which of the following is a contraindication to the use of this medication?

Active genital herpes

A nurse is assisting with an amniotomy for a client who is in active labor. Which of the following actions should the nurse take?

Assess the fetal heart rate before and after the procedure

A nurse is caring for a client who is in labor and received meperidine for pain 1 hr prior to entering the second stage of labor. Which of the following actions should the nurse take?

Assess the newborn for respiratory depression

A nurse is assessing a newborn and notes an axillary temperature of 96.9°F (36°C). Which of the following actions should the nurse perform?

Assess the newborn's blood glucose level

A nurse is caring for a recently delivered newborn whose mother had gestational diabetes. What action should the nurse take within 1 hr after birth?

Assess the newborn's blood glucose level

A nurse is creating a plan of care for a client who is in the active stage of labor and expresses a desire to use nonpharmacological methods of pain relief. Which of the following interventions should the nurse include?

Assist the client into a warm shower

A nurse is caring for a client who is at 38 weeks gestation and in the active phase of the first stage of labor. The nurse notes 2 late decelerations of the fetal heart rate during the last 5 contractions. Which of the following actions should the nurse take?

Assist the client to a lateral position

A nurse is assessing a client who is 14 hr postpartum and has a thirddegree perineal laceration. The client's temperature is 37.8°C (100°F), and her fundus is firm and slightly deviated to the right. The client reports a gush of blood when she ambulates and no bowel movement since delivery. Which of the following actions should the nurse take?

Assist the client to empty her bladder

A nurse is caring for a client at 32 weeks gestation who is experiencing preterm labor. Which of the following medications should the nurse plan to administer?

Betamethasone

A nurse is caring for a client who is experiencing preterm labor. Which of the following medications should the nurse anticipate administering to enhance fetal lung maturation?

Betamethasone

A nurse is caring for a client who has a prescription for naloxone. Which of the following is the intended action of the medication in relation to the central nervous system (CNS)?

Block the effects of narcotics on the CNS

A nurse is providing teaching to a client who is at 8 weeks gestation about manifestations to report to the provider during pregnancy. Which of the following pieces of information should the nurse include in the teaching?

Blurred or double vision

A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate. The client begins to show indications of magnesium sulfate toxicity. Which of the following medications should the nurse prepare to administer?

Calcium gluconate

A nurse is caring for a client who is receiving magnesium sulfate IV. Which of the following medications should the nurse have available as an antidote to magnesium sulfate?

Calcium gluconate

A nurse is caring for a client who is receiving magnesium sulfate by continuous IV infusion. Which of the following medications should the nurse have available at the client's bedside?

Calcium gluconate

A nurse is caring for a client who is at 39 weeks gestation and shows manifestations of labor. Which of the following findings will alert the nurse that the client is in true labor?

Changes in cervical dilation or effacement

A nurse is providing teaching about the selection of commercial formula to the guardian of a newborn. Which of the following pieces of information should the nurse include?

Cow's milk-based formula is recommended for healthy newborns.

A nurse in a prenatal clinic is caring for a client who is within the recommended guideline for weight. The client asks the nurse how much weight is safe for her to gain during her pregnancy. Which of the following responses should the nurse offer?

D. "A weight gain of about 25 to 35 lb is good."

A nurse is caring for a newborn who is premature in the neonatal intensive care unit. Which of the following actions should the nurse take to promote development?

Position the naked newborn on the parent's bare chest

A nurse is caring for a client at 35 weeks gestation who has severe preeclampsia. Which of the following assessments provides the most accurate information regarding the client's fluid and electrolyte status?

Daily weight

A nurse is assessing a client who is at 12 weeks gestation and has a hydatidiform mole. Which of the following findings should the nurse expect?

Dark brown vaginal discharge

A nurse is assessing a client at 34 weeks gestation who has a mild placental abruption. Which of the following findings should the nurse expect?

Dark red vaginal bleeding

A nurse is caring for a client in the latent phase of labor who is receiving oxytocin via continuous IV infusion. The client is having contractions every 2 min that last 100 to 110 sec, and the fetal heart rate (FHR) is reassuring. Which of the following actions should the nurse take?

Decrease the dose of oxytocin by half

A nurse is planning care for a client who is postpartum. Which of the following strategies should the nurse include in the plan to prevent bladder distention?

Run water in the sink while the client sits on the toilet

A nurse is reviewing the laboratory findings of a 24-hour-old newborn. Which of the following findings should the nurse report to the provider?

Hemoglobin 12 g/dL

A nurse is caring for a client who is scheduled to receive a spinal anesthetic. Which of the following actions should the nurse plan to perform?

Infuse a 500 mL bolus of 0.9% sodium chloride immediately prior to the procedure

A nurse is caring for a term newborn 90 minutes after a scheduled cesarean birth. The newborn's 1-minute Apgar score was 9. The newborn's heart rate is 120/min, and his respiratory rate is 70/min. There are no indications of retractions, grunting, or nasal flaring. Which of the following actions should the nurse take?

Initiate close observation of the newborn for indications of respiratory distress

A nurse in a prenatal care clinic answers a phone call from a client who is at 37 weeks gestation and reports, "I became very dizzy while lying in bed this morning, but the feeling went away when I turned onto my side." Which of the following actions should the nurse take?

Instruct the client about vena cava syndrome and measures to prevent it

A nurse is caring for a client who is 3 days postpartum and has chosen to formula-feed her newborn. During an examination of the client's breasts, the nurse notes that they are warm and firm. Which of the following actions should the nurse plan to take?

Instruct the client to apply cold compresses

A nurse is planning care for a client who is scheduled to have prostaglandin E2 gel inserted for cervical ripening. Which of the following actions should the nurse take?

Maintain the client in a side-lying position for 30 min after insertion

A nurse is caring for a client who is 2 hr postpartum. The nurse notes the client's perineal pad has a large amount of lochia rubra with several clots. Which of the following actions should the nurse perform first?

Massage the fundus

A nurse is caring for a newly admitted newborn who is large for gestational age. After 30 min, the newborn becomes jittery and lethargic with hypotonic muscles and a cry that is different from the time of admission. Which of the following actions should the nurse take?

Perform a heel stick to check the newborn's glucose level

A nurse is reviewing the medical record of a client at 33 weeks gestation who has placenta previa and bleeding. Which of the following prescriptions should the nurse clarify with the provider?

Perform a vaginal examination

A nurse is caring for a client who is receiving oxytocin to induce labor. Which of the following actions should the nurse take?

Perform continuous fetal heart rate monitoring

A nurse is discussing the expected changes related to pregnancy with a client who is at 8 weeks gestation. Which of the following findings should the client to report to the provider during the first trimester?

Persistent vomiting

A nurse is initiating phototherapy for a newborn who has hyperbilirubinemia. Which of the following actions should the nurse take?

Place an opaque mask over the newborn's eyes

A nurse is caring for a client in active labor who is experiencing hypotension following epidural placement. Which of the following actions should the nurse take?

Place the client in a lateral position

A nurse is assisting with the care of a client who is in labor. The nurse observes late decelerations on the fetal monitor. Which of the following actions should the nurse take?

Place the client in a left lateral position

A nurse is caring for a client who is in labor. The nurse observes late decelerations on the fetal monitor. Which of the following actions should the nurse take?

Place the client in a left lateral position

A nurse is caring for a newborn immediately following delivery. Which of the following actions should the nurse perform first?

Place the newborn directly on the client's chest

A nurse is teaching the guardian of a newborn about car seat safety. Which of the following pieces of information should the nurse include?

Place the shoulder harness in the slots that are level with the newborn's shoulders

A nurse is caring for a client who recently gave birth and plans to breastfeed. Which of the following actions should the nurse take?

Place the unwrapped newborn on the mother's bare chest

A nurse in a prenatal clinic is reviewing the laboratory results of a client who is at 33 weeks of gestation. For which of the following results should the nurse notify the provider?

Platelet count 135,000/mm^3

A nurse is caring for a preterm infant in the NICU. Which of the following actions by the nurse will promote the infant's optimal development?

Reducing ambient noise and lighting

A client who is pregnant tells the nurse that she is financially unable to buy the food and vitamins recommended during pregnancy. Which of the following actions should the nurse take?

Refer the client to a community resource that could assist with providing nutrition

A nurse is caring for a client who has oligohydramnios. Which of the following fetal anomalies should the nurse expect?

Renal agenesis

A nurse is obtaining the blood pressure of a client who is pregnant. The client's blood pressure is 142/90 mmHg. Which of the following actions should the nurse take?

Repeat the measurement after allowing the client to sit for 5 to 10 minutes

A nurse is reviewing the medical record of a client who is at 20 weeks of gestation. Which of the following findings should the nurse identify as a presumptive indication of pregnancy?

Report of fetal movement by the client

A nurse is caring for a newborn whose mother received magnesium sulfate to treat preterm labor. Which of the following clinical manifestations in the newborn indicates toxicity due to the magnesium sulfate therapy?

Respiratory depression

A nurse is discussing risk factors for necrotizing enterocolitis (NEC) in newborns with a newly licensed nurse. Which of the following risk factors should the nurse include?

Respiratory distress syndrome

A nurse is caring for a preterm newborn who is receiving oxygen therapy. Which of the following findings should the nurse identify as a potential complication of the oxygen therapy?

Retinopathy

A nurse is caring for a client who had a cesarean birth 36 hours ago and is experiencing pain due to gas. Which of the following strategies should the nurse recommend?

Rock in a rocking chair

A nurse is teaching new parents about newborn reflexes. Which of the following reflexes facilitates infant feeding?

Rooting

A nurse is caring for a newborn who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect and report to the provider?

Tremors

A nurse is planning care for a newborn who is receiving phototherapy. Which of the following interventions should the nurse include in the plan of care?

Turn and reposition the newborn every 2 hours during

A nurse is caring for a client in active labor whose membranes have ruptured. The fetal monitor tracing reveals late decelerations. Which of the following actions should the nurse take first?

Turn the client onto her left side

A nurse is caring for a newborn who is receiving treatment for jaundice with traditional phototherapy lights. Which of the following interventions should the nurse perform?

Turn the newborn every 2 hr

A nurse is assessing a client at 35 weeks gestation who is receiving magnesium sulfate via continuous IV infusion for severe pre-eclampsia. Which of the following findings should the nurse report to the provider?

Urinary output 20 mL/hr

A nurse is assessing a client who is receiving magnesium sulfate as a treatment for pre-eclampsia. Which of the following clinical findings is the nurse's priority?

Urinary output 40 mL in 2 hr

A nurse is assessing a client who is in the fourth stage of labor. Which of the following findings should the nurse expect?

Urinary retention

A nurse is assessing an 18-hour-old newborn. Which of the following findings should be reported to the provider?

Yellow-tinged skin